Cornwall and the Isles of Scilly

Concerns summary Porthleven Harbour and its pier presented significant safety risks due to sheer drops, absent railings, poor lighting, trip hazards, and a lack of escape provisions for anyone falling into the water.

Concerns summary Insufficient funding and staffing within police Communication and Control Units, compounded by inadequate officer numbers, consistently prevent timely responses to incidents, a long-standing issue particularly acute during peak demand.

Concerns summary Persistent understaffing at the care home severely compromises the safe provision of care and treatment, and hinders effective management oversight of care quality.

Concerns summary Systemic delays in discharging medically fit patients from hospital are caused by insufficient intermediate care capacity. Discharging patients to understaffed residential homes results in patient deterioration and re-admissions, exacerbating hospital pressures.

Concerns summary The university lacked mandatory mental health and suicide prevention training for staff, employed an overly reactive, email-based approach to welfare concerns, and had staff unaware of information-sharing policies. Pastoral support was also limited by a lack of direct contact protocols.

Concerns summary Remedial works for dangerous trees at Sailors Creek were not undertaken despite obvious risks, directly contributing to a tragic death.

Concerns summary Inadequate road drainage at a specific location causes dangerous surface water accumulation during heavy rainfall, leading to aquaplaning incidents that could be prevented by feasible improvements.

Concerns summary The absence of a single 'Event Organiser' for public events hinders safety planning and risk management, as authorities lack legal powers to mandate an organiser or refuse unsafe events.

Concerns summary Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance from the Youth Justice Board.

Concerns summary Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no clear guidance on balancing antibiotic use for sepsis against the risk of HUS in bacterial gastroenteritis.

Concerns summary There was a missed opportunity to caseload a dual diagnosis patient, alongside systemic communication issues between agencies regarding record access. Patients were also discharged too readily for missed appointments without considering other support services.

Concerns summary Poor note-keeping and a lack of clear future care planning during discharge, coupled with insufficient family involvement and unavailable crisis support for the carer, exposed the patient to significant risk.

Concerns summary Converging surface water on the A390, exacerbated by heavy rainfall, creates a significant aquaplaning risk. Feasible drainage improvements have not yet been implemented despite a previous incident.

Concerns summary Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without accountability.

Concerns summary A concealed road junction on a downhill stretch lacks warning signs, posing a significant hazard to drivers unfamiliar with the acute turn and stationary vehicles.

Concerns summary There is no national system for circulating patient alerts to pharmacies or GPs regarding inappropriate opiate prescriptions. This allowed the deceased to improperly obtain lethal quantities of medication.

Concerns summary A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an inadequate assessment of a high-risk patient.

Concerns summary Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for suspicious missed appointments or uncollected prescriptions.

Concerns summary Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls will be mitigated by other emergency services, increasing safety risks for bathers.

Concerns summary Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on mitigation strategies or current service levels available to the public.

Concerns summary The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.

Concerns summary The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.

Concerns summary There is insufficient independent data and understanding regarding the lethality and incremental risks of multiple Taser activations, potentially leading to deficient police training and unsafe use.

Concerns summary Care plans were not updated to reflect changing needs or multidisciplinary decisions. There was a lack of appropriate equipment, specialist advice, and staff training in equipment use and moving/handling.

Concerns summary Risks included unsupervised bathing for residents with seizure risk, GP unawareness of critical issues like hoarding, failed medication compliance systems, and inconsistent reporting/monitoring for absconding incidents.